AAFP, USPSTF Recommend Routine HIV Screening but Differ on Age to Begin

Although the AAFP and the U.S. Preventive Services Task Force (USPSTF) each have issued new recommendations calling for routine screening of normal-risk adolescents and adults for HIV infection, the two organizations differ regarding the recommended age at which routine screening should begin.

According to the USPSTF's recommendation(www.uspreventiveservicestaskforce.org), physicians and other health professionals should screen all adolescents and adults ages 15-65 for HIV infection, as well as younger adolescents and older adults who are at increased risk for contracting the disease. The task force also recommends that clinicians screen all pregnant women for HIV infection, including those who present in labor whose HIV status is unknown.

The AAFP's new recommendations on HIV screening reflect those issued by the task force in all aspects but one: the age at which physicians should begin routine screening in teens not at increased risk for infection. According to the Academy, routine screening should not begin until age 18.

Meanwhile, the CDC currently states that routine screening should begin at age 13.

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The U.S. Preventive Services Task Force (USPSTF) has issued a final recommendation proposing that physicians and other health professionals should screen all adolescents and adults ages 15-65 for HIV infection.

In addition, all pregnant women, as well as younger adolescents and older adults who are at increased risk for contracting the disease, should be screened.

A new AAFP recommendation differs from that released by the USPSTF regarding the age at which physicians should begin routine screening for HIV infection, with the AAFP recommending that evidence does not support initiating routine screening until age 18. The CDC currently recommends routine screening starting at age 13.

AAFP liaison to the USPSTF Doug Campos-Outcalt, M.D., M.P.A., of Phoenix, said that although the evidence base is solid for the recommendations regarding adults, evidence does not support beginning routine HIV screening in patients younger than 18.

"We (at the AAFP) believe that below the age of 18, the prevalence of the disease is too low to justify routine screening, and that screening below that age should be based on risk," he said. "Based on the evidence, we just don't think it is a good use of resources and time to be screening low-risk 15-, 16- and 17-year-olds."

Campos-Outcalt, who also is chair of the department of family, community and preventive medicine at the University of Arizona College of Medicine, Phoenix, told AAFP News Now that, according to information provided by the CDC, a rough calculation puts the likelihood of a patient between the ages of 15-19 presenting with HIV infection at 1.3 per every 10,000 patients. That figure, however, was calculated using case numbers that lumped together all teens in that five-year range, he added.

It's not realistic to include teens 18 and 19 with those in the 15- to 17-year-old range, said Campos-Outcalt, because data show younger adolescents are less likely to be sexually active.

"We (at the AAFP) just think that the prevalence is way too low and the benefit is unproven for routine testing in that age group," Campos-Outcalt said. "Now -- and this is a key point -- we do say you should test high-risk kids in that age group.

"If you are taking care of kids who are homeless or in the sex industry and young men who have sex with men -- now that's a different mater, but the routine high-school kid? No."

According to USPSTF Co-vice Chair Michael LeFevre, M.D., M.S.P.H., of Columbia, Mo., the task force's revised recommendation represents a sea change from the statement it published in 2005, which focused on high-risk groups. However, the new guidance makes no specific recommendations regarding how often screening should be performed.

"While the science isn't clear on the best frequency for testing, the task force felt that one-time screening may suffice for low-risk individuals, with those at increased risk getting repeated screenings," LeFevre said. "This would include people who inject drugs and men who have sex with men.

"A key role for family physicians in our efforts to reduce the impact of this important health problem is to make sure everyone is offered the opportunity to be screened and to get people (found to be infected) into the appropriate care very early in the course of their infection."

As for treatment, LeFevre pointed out that because the science surrounding HIV infection has progressed dramatically, what used to be a death sentence now is often more like a manageable chronic disease.